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But starting in November 2016, to facilitate enrollment in plans for 2017, Hawaii switched to a fully-federally-run exchange, although that state still oversees the plans that are sold in the exchange. In September 2016, Hawaii navigator organizations received funding from the federal government for the first time, as the state is no longer playing a role in exchange outreach. Since Hawaii has been using Healthcare.gov for enrollment since the fall of 2015, the switch to a fully federally-run exchange had minimal impact on enrollees and insurers in the exchange.

Many of the concerns that prompted national health care reform and the 2010 passage of the Affordable Care Act were not prominent in Hawaii. Long before the ACA brought health reform to the whole country, Hawaii already enjoyed a low uninsured rate, health insurance plans were required to cover a core set of benefits, and employer-provided coverage was quite affordable.

This good state of affairs is largely due to the Hawaii Prepaid Health Care Act, which was enacted in 1974. The Prepaid Health Care Act requires employers to provide health insurance to employees who work more than 20 hours a week and to pay 50 percent of premiums. “Affordability” for employees is defined as 1.5 percent of income, compared to 9.78 percent (in 2020) under the ACA.

Given Hawaii’s small population and its historically low uninsured rate, implementing a state-run exchange was a questionable financial decision. According to Kaiser Health News, the Hawaii Health Connector was the nation’s most expensive exchange on a per-enrollee basis in 2014, at $23,899 per enrollee. Ultimately, Hawaii began using HealthCare.gov as of the fall of 2015, and more than 20,000 Hawaii residents have private, individual market coverage in the state’s federally-run exchange.

Hawaii is no longer allowing transitional (grandmothered) individual market plans to exist after the end of 2019, although transitional small group plans can remain in force through the end of 2020 (and possibly longer, depending on future federal extensions). The federal government has continued to allow these plans to renew, but at each state’s discretion. In 2018, Hawaii agreed to allow transitional plans in both the individual and small group markets to remain in force throughout 2019, but the state’s extension for 2020 only applies to small group plans. Although individual market transitional plans were allowed to remain in force in Hawaii in 2019, HMSA opted to terminate all of their individual market transitional plans at the end of 2018 (that’s according to SERFF filing HMSA-131977825, in which HMSA notes that about two-thirds of those enrollees subsequently enrolled in ACA-compliant HMSA plans for 2019).

Enrollment in Hawaii’s exchange: 2014 to 2019

20,169 people enrolled in private plans (QHPs) through Hawaii’s exchange during the open enrollment period for 2020 coverage. That was a slight decrease from the 20,193 people who had enrolled the year before, for 2019 coverage.

8,592 people enrolled in private plans through Hawaii’s state-run exchange for 2014. Open enrollment lasted for six months that year (October 2013 through March 2014), and there were additional extensions tacked on at the end; that enrollment total is through April 19, 2014.

12,625 people enrolled in private plans for 2015 through Hawaii’s state-run exchange.

As noted above, enrollment grew again in 2019, but it declined slightly for 2020.

There were very conflicting reports about Hawaii Health Connector’s total enrollment in those first two years. The executive director’s report from July 2015 showed 33,479 individuals enrolled, but that was dramatically higher than the roughly 13,000 people who were reported to have enrolled during open enrollment. And HHS was reporting only 8,200 people with effectuated coverage as of March 31, 2015.

I contacted the exchange to clear up the confusion. Executive Director Jeff Kissel claimed that the larger number was much more accurate. He said that the discrepancy stemmed from a significant lag time in enrollment reporting from carriers. Kissel said that the Connector’s in-force enrollment total as of late July 2015 was roughly 20,000 people with HMSA and 11,000 people with Kaiser.

And by early September, when HHS released a report stating that Hawaii Health Connector’s effectuated enrollment as of June 30 stood at 8,802 people, Kissel said that the actual total had grown to 35,600, and that the HHS report wasn’t including HMSA enrollments.

But in November 2015, Kaiser reported that just 7,300 of their 16,800 enrollees had used Hawaii Health Connector to purchase their coverage (the remaining 9,500 people enrolled directly through Kaiser). And HMSA reported that fewer than half of their enrollments (10,000 out of 21,000 total enrollees) had come through the exchange in 2015.

These reports indicate that total enrollment was probably considerably lower than what was being reported by the exchange in 2015. In December 2015, Governor Ige noted that the state had “always had challenges getting accurate numbers from the Connector.” and explained that the discrepancies might be “one of the reasons the federal government had concerns.” Ultimately, HHS began running Hawaii’s exchange as of 2016, eliminating enrollment discrepancies from that point forward.

2020 health insurance rates and plans, plus a look at how rates have changed since 2014

Hawaii’s exchange has two insurers that offer individual market coverage. For the first time since ACA-compliant plans debuted, overall average rates in Hawaii’s individual market are decreasing for 2020, with both carriers reducing their average premiums:

HMSA: average rate decrease of 3.3 percent. HMSA had initially proposed an average decrease of 1.7 percent, but revised their filing in September 2019, noting that they were proposing lower rates because they had revised their assumptions regarding how much of an impact the elimination of the ACA’s individual mandate penalty was having on the morbidity of the risk pool. In other words, the risk pool wasn’t deteriorating as much as they had expected without the individual mandate penalty. The details are in SERFF filing HMSA-131977825. HMSA has approximately 19,000 members.

Kaiser: average rate decrease of 5.4 percent. Kaiser had initially proposed a slight rate increase, but revised it later on, noting that their risk adjustment payments were expected to be lower than they had originally anticipated.

As is always the case when we talk about average rate changes, this refers to full-price premiums. People who have off-exchange plans pay full price, and so do about 15 percent of on-exchange enrollees in Hawaii. But for the other 85 percent of on-exchange enrollees, changes in after-subsidy premiums can be very different, depending on how much the subsidy amount itself is changing (when benchmark premiums go down, so do premium subsidy amounts).

For perspective, here’s a look back at how rates have changed over the years in Hawaii. The decrease for 2020 comes on the heels of a slight increase in 2019, but rate increases for 2016, 2017, and 2018 were much more substantial:

For 2015, average rates in Hawaii’s individual market increased by about 7.8 percent (9.2 percent for Kaiser and 3.8 percent for HMSA).

For 2016 coverage, HMSA proposed a 45.5 percent rate increase for their individual HMO plan, and nearly a 50 percent rate hike for their individual PPO plan (49.1 percent overall). The following day, Kaiser proposed an 8.7 percent rate increase for their individual market policies. Insurance Comissioner Gordon Ito said in June 2015 that HMSA’s proposed rates would be “closely scrutinized.” Ultimately, for 2016 individual market plans, MHSA ended up with a rate increase that was smaller than requested, while Kaiser’s rates increased much more than they had projected. Across both insurers, the weighted average rate increase was 30 percent for 2016.

For 2018, rates increased significantly for the third year in a row. HMSA increased their average rates by nearly 26 percent, and Kaiser increased theirs by more than 24 percent. In both cases, these rate increases were based on the assumption (which ended up being correct) that the federal government would not continue to fund cost-sharing reductions (CSR). The Hawaii Department of Insurance confirmed in early October 2017 that they had instructed the insurers to assume that CSR funding wouldn’t continue, and to apply the resulting additional premiums to on-exchange silver plans. (Hawaii has continued to take this approach ever since, with the cost of CSR added to silver plan rates in the exchange)

For 2019: HMSA decreased their premiums slightly (by less than half a percent), while Kaiser increased theirs by almost 13 percent. The weighted average rate increase for 2019 was about 5.3 percent, as opposed to the 13.8 percent weighted average rate increase the insurers had proposed. The Hawaii Division of Insurance noted that the approved rates would save consumers $20 million in 2019, in comparison with what consumers would have had to pay if the initially filed rates had been approved without modification.

2018 legislation passed to limit short-term plans and codify ACA protections into state law. Bills to create a Hawaii reinsurance program and impose an individual mandate did not pass

The ACA’s future was uncertain in 2017, and Hawaii lawmakers passed legislation (H.B.552/Act 43) that year to create a working group tasked with recommending ways the state could preserve the ACA’s consumer protections, regardless of federal action.

The final version of the bill, signed into law by Governor David Ige in June 2017, was much less robust than earlier versions. The initial version of the bill that the House passed would have preserved some ACA provisions, regardless of what happens on the federal level (Hawaii’s legislature is overwhelmingly Democratic). The initial House version of H.B.552 would have preserved the individual mandate, minimum essential benefits requirements, dependents allowed on parents’ health plan until age 26, and the ACA’s ban on preexisting condition exclusions and gender-based premiums.

That version passed the House in early March. The Senate passed H.B.552 on April 11, but with additional amendments (SD2) that went further than what the House had proposed. The Senate’s amendments would have created a Medicaid Plus program to provide coverage to Hawaii residents with income between 138.5 percent and 250 percent of the federal poverty level, and created a trust fund to reimburse insurers for the costs of providing minimum essential insurance benefits. The Senate’s amendments also would have exempted people with household income up to 250 percent of the poverty level from the state’s individual mandate.

Since the two chambers had passed different bills, a conference committee then began meeting to reach an agreement, and on April 27, 2017 the House and Senate both agreed to a much less robust version of the bill. The version that was passed and signed into law denounced the federal GOP-led efforts to repeal the ACA, detailed the ways that the ACA has benefitted Hawaii, and called for the formation of a working group (no later than August 1, 2017) that would make recommendations for preserving a variety of ACA provisions, including minimum coverage requirements, essential health benefits, and Medicaid expansion.

The Affordable Health Insurance Working Group was created after the bill was signed into law, meeting in September, October, and November 2017. The working group published their report in January 2018. The report outlined a few recommended legislative proposals, which included directing the state to apply for another 1332 waiver in order to obtain federal funding for a state-based reinsurance program, as well as legislation to codify the provision that allows young adults to remain on a parent’s health insurance until age 26. The working group also recommended legislation to prohibit insurers from basing premiums on applicants’ genders or rejecting applicants with pre-existing conditions.

H.B.1520, which was signed into law in July 2018, essentially eliminated the market for short-term health insurance in Hawaii. The legislation stipulates that a short-term plan can’t be more than 90 days, and it prohibits an insurer from selling (or renewing) a short-term policy to anyone who was eligible to purchase coverage in the exchange during the previous calendar year, either during open enrollment or a special enrollment period.

Virtually everyone in Hawaii is eligible to purchase coverage in the exchange. The only exceptions are people who aren’t legal US residents, people who are enrolled in Medicare, and people who are incarcerated. So now that H.B.1520 has been enacted, there are very few people to whom short-term insurers can market their plans. By early October 2018, there was still at least one insurer offering short-term plans in Hawaii. But those plans were no longer for sale as of late October 2018, and no other short-term plans have been introduced into the state’s market since then.

S.B.2340, which was signed into law in July 2018, codified three of the ACA’s consumer protections into state law. The legislation:

Ensures that young adults can continue to remain on their parents’ health insurance plans until age 26

Prohibits insurers from using applicants’ gender to set premiums

Prohibits insurers from rejecting an application based on an applicant’s medical history, or imposing coverage exclusions based on pre-existing conditions.

The purpose of this legislation was to ensure that these ACA provisions remain in effect in Hawaii, regardless of any potential changes to the ACA at the federal level. Hawaii lawmakers wanted to ensure that at least some of the ACA’s most popular provisions will continue to be the law in Hawaii, regardless of potential changes at the federal level.

H.B.2146 and S.B.2199, which did not pass, would have directed the state to submit a 1332 waiver to the federal government, in order to obtain federal funding for a reinsurance program in Hawaii. The idea is that certain high-cost claims would be covered by the reinsurance program, thus reducing premiums for everyone in the individual market. Lower premiums mean lower premium subsidies, and the 1332 waiver would be used so that the money the federal government saves on premium subsidies would be sent to Hawaii for the state to fund the reinsurance program. Several other states have implemented reinsurance programs, and have seen significant stabilization in their individual markets as a result. But several other states have opted against reinsurance programs, generally due to concerns about how to fund the state’s portion of the cost.

Hawaii was the first state in the country to receive federal approval of a 1332 waiver, which allowed them to end their SHOP exchange for small businesses. H.B.2146/S.B.2199 called for a second 1332 waiver, devoted to obtaining federal funding for reinsurance. Ultimately, however, the legislation did not advance during the 2018 session.

S.B.2924 and H.B.2209, which did not pass, would have created an individual mandate in Hawaii, effective in 2019. The ACA’s individual mandate penalty is $0 in 2019 and beyond, essentially eliminating the individual mandate (the federal mandate technically remains in effect, but there is no longer any associated penalty, so there is no method for enforcing the mandate). S.B.2924 passed the Senate by a vote of 24-1 in March 2018, but did not advance in the House Finance Committee.

Hawaii eliminated SHOP exchange as of 2017; First approved 1332 waiver in the nation

As of 2017, Hawaii no longer has a SHOP exchange for small businesses. The State Department of Labor and Industrial Relations has an FAQ page about this.

In September 2015, Hawaii became the first state to post a draft 1332 innovation waiver. In June 2016, the state officially submitted its 1332 waiver proposal. In response to a July request from HHS for more details, Hawaii submitted a revised 1332 waiver proposal in August 2016, and requested approval from HHS in time for the waiver to become effective for 2017.

In late September 2016, HHS acknowledged receipt of a complete 1332 waiver from Hawaii, and noted that the federal government would make a decision within 180 days (no later than March 25, 2017).

On December 30, CMS sent a letter to Hawaii Governor, David Ige, informing him that the 1332 waiver had been approved for five years, effective January 1, 2017, through December 31, 2021. The only portion of the waiver proposal that wasn’t approved was a provision that would have allowed agencies other than the Hawaii Medicaid Agency to have a role in the exchange; CMS noted that this was no longer applicable, since HealthCare.gov runs the exchange in Hawaii now.

Hawaii’s waiver aligns the ACA with the state’s existing Prepaid Health Care Act. Under the Prepaid Healthcare Act, employees who work at least 20 hours a week have to be offered employer-sponsored health insurance, and can’t be asked to pay more than 1.5 percent of their wages for employee-only coverage (as opposed to 9.69 percent under the ACA in 2017). And unlike the ACA’s employer mandate (which only applies to businesses with 50 or more workers), the Prepaid Health Care Act applies to all businesses, regardless of how few employees they have. In its 1332 waiver proposal, Hawaii “proposes to waive provisions in Sections 1301, 1304, 1311, and 1312 of the Affordable Care Act that enumerate marketplace requirements that conflict with Prepaid.”

Hawaii’s 1332 waiver proposal “is primarily focused on waiving the need to establish and maintain a state-based SHOP exchange or participate in a federal SHOP exchange.” The state sought to avoid the ACA’s SHOP exchange requirements, since they already have an employer-sponsored insurance system that they believe is more effective and affordable for employers than the ACA’s SHOP exchange. They also note that Hawaii cannot use the federally-facilitated SHOP exchange on HealthCare.gov, because it “does not inform Hawai‘i employers of their Prepaid-specific obligations and options.”

Enrollment in SHOP was very low in Hawaii (as was the case in most states). Hawaii notes that only about 1,000 employees had coverage through the state’s SHOP exchange as of June 2016, while 742,000 had coverage under Hawaii’s Prepaid Health Care Act. And only one of the state’s four group insurance carriers offered plans through SHOP in 2016. The state-run SHOP exchange shut down in June 2015 as part of the transition to a federally-supported state-based marketplace, and small businesses had just been enrolling directly through Kaiser (the only carrier that participated in SHOP) since then (HMSA had offered SHOP coverage in 2014, but announced in August 2014 that they would not be offering small business plans through the Connector starting in 2015, due mainly to the technological problems with the exchange. That left Kaiser as the only small business option on the Connector as of 2015).

Under the approved 1332 waiver, Hawaii businesses can no longer participate in SHOP for plan years that begin on or after January 1, 2017, but plans that started in 2016 could continue through their renewal date in 2017. The ACA’s small business tax credit is not available in Hawaii for plan years that begin on or after January 1, 2017, but CMS will give the money they would have spent on the small business tax credit (estimated at about $2.8 million over five years) to the state, and they can use it to implement the 1332 waiver, including payments to small employers who are eligible for the state’s Premium Supplementation Program.

$459,169 of that funding was for 2017, and the first payment from CMS were to be sent to Hawaii in October 2017. Although the 1332 waiver is effective for five years, future pass-through funding for the state (in lieu of the small business tax credit) assumes that the ACA’s small business tax credit continues to exist.

Subsidy eligibility for COFA nation residents

With the exception of Hawaii, the rest of the states have very few QHP enrollees with income below the poverty level. In states that have expanded Medicaid, residents with income below the poverty level are eligible for Medicaid. And in states that haven’t expanded Medicaid, residents with income below the poverty level are stuck in the coverage gap, and very few can afford to pay full price for health insurance through the exchange (no subsidies are available to people in the coverage gap).

In every state, people who would be eligible for Medicaid based on income, but aren’t eligible because of immigration requirements (ie, they haven’t been in the US for at least five years) are eligible for premium subsidies in the exchange. If their income is less than the poverty level, they’re eligible for subsidies as if their income were 100 percent of the poverty level. By and large, this is why most states’ exchanges have somewhere between one percent and four percent of their enrollees with income under the poverty level (although it also includes some people in the coverage gap who have purchased full-price coverage, and some people who would have been eligible for Medicaid but have opted instead to pay full price for a QHP in the exchange).

But in Hawaii, nearly a third (29 percent) of the people who enrolled in QHPs through the exchange had income below the poverty level as of 2016. That’s because COFA nation residents are eligible for premium subsidies in the exchange even if their income is below the poverty level. They used to be eligible for state-funded Medicaid, but they’ve been transitioned to premium subsidies in the exchange instead; federal Medicaid expansion won’t cover COFA nation residents, but they are eligible for premium subsidies (Andrew Sprung has a nice explanation of how this all works).

Since 2017, CMS no longer breaks out the percentage of enrollees with income below the poverty level. The enrollment reports for 2017, 2018, and 2019 have lumped into one income category (“other FPL) all enrollees with income below the poverty level as well as those with income above 400 percent of the poverty level.

Hawaii’s exchange was troubled from the start; state switched to HealthCare.gov as of 2016 (and a fully federally-run exchange as of 2017)

In addition to administrative and technical problems, Hawaii Health Connector faced financial challenges, mostly because of relatively low enrollment and a small pool of eligible enrollees. Marketplace officials spent much of 2014 looking for alternative funding models as well as ways to cut expenses. Federal funding for state-run marketplace operations ran out at the end of 2014. The state allocated $1.5 million of a $4 million request to fund exchange operations through June 2015, the end of the fiscal year.

Hawaii Health Connector planned to use a 2 percent fee on premiums to fund its ongoing operations. Given low enrollment, the premium fee wasn’t generating enough revenue to meet annual expenses, estimated at anywhere between $4.5 and $15 million, according to the Associated Press.

The Hawaii Senate in 2015 approved a bill that would have allowed Hawaii Health Connector to issue up to $28 million in state bonds over ten years to fund its operations until it became self-supporting. However, a House committee stripped the bonding provision from the bill.

In January 2015, Executive Director Jeffrey Kissel (who took over the exchange in October 2014) acknowledged “deficiencies in the planning process, procurement, and governance” following the release of a highly critical state audit. The audit found inadequate planning by the Connector’s board of directors led to an unsustainable health exchange, and improper procurement processes, contract administration, and financial oversight put federal grants at risk.

The Connector’s eligibility system was not integrated with the state’s Medicaid system, which caused significant enrollment delays and was another reason the exchange wasn’t compliant with federal regulations.

Another major problem with Hawaii Health Connector was the lack of anonymous browsing — consumers had to create an account before they could compare plans. That same design flaw was a major source of congestion and frustration with the original version of HealthCare.gov (the federal marketplace was soon revamped to allow browsing).

In May 2015, the Hawaii legislature approved just $2 million in funding for Hawaii Health Connector — a far cry from the $10 million the exchange had requested. Lawmakers has been considering up to $5.4 million for the exchange, but ultimately approved less than half that amount (SB 1028 is the legislation that granted the $2 million).

HHS notified the state in March 2015 that Hawaii Health Connector wasn’t complying with the requirement that it be financially self-sustaining as of January 2015. As a result, the federal government began preparations for a possible transition to Healthcare.gov, and the remaining $70 million in federal funding for the exchange was frozen ($204 million had been allocated to the Hawaii Health Connector; $130 million had already been spent by the time the federal government notified the exchange that a switch to Healthcare.gov would likely be necessary).

In June 2015, the Hawaii Health Connector Board approved a plan to transition to Healthcare.gov by October, in time for the 2016 open enrollment period that began November 1, 2015. The exchange became a federally-supported state-based model, with HealthCare.gov handling enrollment, while the state continued to oversee customer service and outreach. But for 2017, Hawaii transitioned to having a fully-federally-run exchange.

Initially, the exchange was slated to cease its operations by September 2015. But in late August, the Connector reached an agreement with the state and federal governments to allow them to continue to provide outreach and enrollment assistance during the 2016 open enrollment, with the state paying roughly $3.3 million, and the federal government contributing $2.8 million. With this funding, it was expected that the Connector would remain operational for outreach activities through October 2016, with enrollments conducted through Healthcare.gov.

But on November 19, 2015 (after open enrollment for 2016 was already underway), amid concerns that the exchange had run out of money, the exchange’s executive committee voted to recommend that Hawaii Health Connector speed up the transition of remaining exchange functions to the state of Hawaii. In a press release regarding the move to shutter the exchange sooner than anticipated, Governor Ige noted that “the Connector’s ongoing financial challenges have forced the state to accelerate the transition beginning December 1, 2015.”

As a result of the abrupt shut-down of Hawaii Health Connector, the state worked out a contract with local IT company ike/DataHouse, to ensure that Forms 1095-A were processed and mailed to enrollees and the IRS for 2015. The forms were mailed in January 2016, but up to 80 percent of them contained errors, and the state was working to get corrected forms generated and mailed as of mid-March 2016.

In February 2016, Hawaii Attorney General Douglas Chin filed a request to dissolve the Hawaii Health Connector and have the court appoint a receiver for “the remaining charitable assets of the exchange.” Chin noted that the dissolution process would reveal what assets remained, but he also said that the exchange’s assets were being “misapplied or wasted.”